Should I hold Brillinta (ticagrelor) in a patient with ongoing bleeding from a cut finger?

Management of Ongoing Bleeding in a Patient on Brillinta (Ticagrelor)

For a patient with ongoing bleeding from a finger laceration while on Brillinta, you should hold the next dose of ticagrelor until hemostasis is achieved, then resume therapy once bleeding has completely stopped. 1

Immediate Management Algorithm

Step 1: Withhold Ticagrelor During Active Bleeding

• Do not give the next scheduled dose of ticagrelor while bleeding is active. 1
• This applies to non-severe bleeding (such as a finger laceration) that does not require hospitalization or transfusion but has not achieved hemostasis despite initial ER management. 1
• The reversible binding mechanism of ticagrelor means platelet function begins recovering within 7-9 hours after the last dose, unlike irreversible agents like clopidogrel or prasugrel. 1

Step 2: Optimize Local Bleeding Control

• Focus on aggressive local measures first: direct pressure, topical hemostatic agents, and proper wound care. 1
• Good local control is critical because there is no specific reversal agent for ticagrelor. 1
• Platelet transfusion is generally ineffective for ticagrelor-related bleeding because the drug remains active in circulation and will inhibit transfused platelets. 1

Step 3: Consider Supportive Hemostatic Measures

• Antifibrinolytics (such as tranexamic acid) or desmopressin may be used to support hemostasis, though they do not reverse ticagrelor's platelet inhibitory effects. 1
• These adjunctive measures can be helpful while waiting for the drug's effect to wear off naturally. 1

Critical Decision Points for Resuming Ticagrelor

Assess the Indication for Ticagrelor

The decision to resume ticagrelor depends heavily on why the patient is taking it and when their cardiac event occurred:

High-Risk Scenario (Recent Stent or ACS):

• If the patient had a stent placed within the past 2 weeks or presented with acute coronary syndrome (ACS) within the past month, they are at very high risk of stent thrombosis. 1
• In this situation, resume ticagrelor as soon as hemostasis is achieved (typically within 24-48 hours for a finger laceration). 1
• The consequences of stent thrombosis (death or massive MI) far outweigh the risk of minor rebleeding from a finger. 1

Lower-Risk Scenario (Remote Event):

• If the patient's MI or stent placement occurred more than 12 months ago, the thrombotic risk is significantly lower. 2
• You have more flexibility to hold ticagrelor for 3-5 days if needed to ensure complete wound healing. 1, 2
• After 12 months post-event, patients are at standard rather than high thrombotic risk. 2

Timing for Resumption

• Resume ticagrelor once hemostasis has been achieved and there is no concern for rebleeding. 1
• For a simple finger laceration, this typically means 24-48 hours after bleeding has completely stopped with proper wound care. 1
• If the patient requires a procedure or suturing, ticagrelor should be held for at least 5 days before the procedure when possible. 1, 3

Important Caveats and Pitfalls

Do Not Attempt Reversal with Platelet Transfusion

• Platelet transfusion is ineffective for ticagrelor because the drug's half-life is 7-9 hours and active drug will inhibit transfused platelets. 1
• This differs from irreversible agents where transfusion may provide some benefit. 1

Consider Concomitant Aspirin

• If the patient is on dual antiplatelet therapy (ticagrelor plus aspirin), consider holding aspirin as well during active bleeding. 1
• Aspirin can be safely discontinued temporarily in most scenarios, though this should be weighed against the specific cardiac indication. 1, 2

Avoid Bridging with Heparin

• Do not use low-molecular-weight heparin or other anticoagulants as "bridging therapy" while ticagrelor is held—this does not reduce stent thrombosis risk and increases bleeding risk. 1
• The only exception is patients at extremely high risk (recent proximal LAD stent within 2 weeks) where IV cangrelor or GP IIb/IIIa inhibitors might be considered in consultation with cardiology. 1

Contact the Prescribing Cardiologist

• For patients within 30 days of ACS or stent placement, discuss with the patient's cardiologist before holding ticagrelor for more than 24-48 hours. 1
• The cardiologist can help assess individual thrombotic risk and may recommend alternative strategies. 1

When to Seek Higher Level Care

Escalate management if:

• Bleeding continues despite 2+ hours of direct pressure and local measures. 1
• Patient develops hemodynamic instability or requires blood transfusion. 1
• Patient has severe anemia at baseline or develops symptoms of anemia. 1
• Patient is within 2 weeks of stent placement and requires prolonged interruption of antiplatelet therapy. 1